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t <br />g" t" SAN JOAQUIN COUNTY <br />- ` X ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: Www.sjgov.org/ehd <br />VECTOR CONTROL INSPECTION FORM <br />Structure <br />Operatbn <br />DBAINSPECTION <br />> <br />DATE <br />/ <br />❑ <br />111. <br />Well Construction <br />PREMISE ADDRESS <br />S <br />RE -INSPECTION DATE <br />❑ ❑ 2. Cross -Connection <br />Structure <br />Operation <br />Manure Management <br />OWNER/OPERATOR <br />PHONE <br />S -3 <br />❑ ❑ 3. Spreading and Disking <br />❑ <br />❑ <br />1 4. Concrete Tanks <br />INSPECTION TYPE <br />PROGRAM ELEM/7 LlENT <br />ei <br />RECORD 1 <br />El C]5. Lagooning <br />❑ <br />❑ <br />6. Composting <br />The items below <br />represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Disposal <br />4t4 t r <br />❑ ❑ 7. Burying with 2" of Cover <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />iV4 f <br />❑ ❑ 9. Removal from Premises <br />Structure <br />Operation <br />Vector Control <br />❑ ❑ 10. Domestic FI <br />El <br />11. Fannia FI <br />® <br />" <br />❑ ❑ 12. Larvae <br />❑ <br />❑ <br />13. Pupae <br />❑ ❑ 14. Adult <br />❑ <br />❑ <br />15. Light Population <br />` <br />K <br />❑ ❑ 16. Moderate Population <br />❑ <br />❑ <br />17. Heavy Population <br />and <br />aAzaZ4ak4c <br />i ow <br />i;k- <br />Structure Operation FeedingAMater <br />❑ <br />❑ <br />18. Water Troughs <br />❑ ❑ 19. Cups or Bowls <br />20. Food Storage <br />Structure operation Houses <br />❑ <br />❑ <br />21. Floors <br />❑ ❑ 22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleanin Fr uenc <br />Structure <br />Operation <br />Water Well <br />❑ 1 1. Well Constructionr <br />El2. <br />Cross Connection <br />Structure Operation Floors <br />❑ <br />❑ <br />3. Properly Graded to Sewer <br />rR <br />❑ ❑ 4. Drain <br />❑ <br />❑ <br />5. Smooth/Cleanable <br />Vw _ <br />r - <br />❑ 6. Coving <br />7. Cleaning Frequency <br />Structure Operation Walls <br />❑ <br />❑ <br />8. Smooth/Cleanable <br />_ <br />❑ ❑ 9. Cleaning Frequency <br />Structure <br />Operation <br />Cages <br />le <br />❑ ❑ 10. Condition <br />11. Sanitation <br />ALI V/'0Q <br />Structure Operation Food <br />❑A <br />❑ <br />12. Storage <br />13. Insect/Vermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ <br />❑ <br />15. Other <br />Structure Operation Sewage Disposal <br />❑ <br />❑ <br />16. Septic System <br />❑ ❑ 17. Sewer <br />Structu <br />erition <br />Rabies Vaccination <br />RECEIVED Ye <br />INSPECTqR <br />1:1❑ 18. Certificate on Premises <br />VL:(; I UK GUN I KUL INSP€GTIUN FORM ' - <br />EHD 40-06 12/04/08 / <br />Page of <br />